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BackgroundRates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours.ObjectiveThis qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience.MethodSemi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically.ResultsThere were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. ‘Informal’ learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients.ConclusionsThe emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions.

The art and science of surgery were never more effectively demonstrated than as seen in the clinical practice of the Cardiff vascular surgeon, Gordon Edyvean Heard. In the 1960s vascular surgery was still in the early stages of development. The major arteries of the body can be diseased with atherosclerosis and other intrinsic defects resulting in dilatation (aneurysm) or blockage. Unblocking and repair or replacement of arteries became possible with the development of new surgical techniques and the development of methods for replacing damaged blood vessels. Rupture of an aneurysm of the major aortic artery, either in the chest or, more commonly, in the abdomen, is a life threatening emergency requiring prompt surgical intervention. In the UK, one in 25 men between the ages of 65 and 75 have an abdominal aortic aneurysm, with rupture causing 6000 deaths each year. Heard was at the forefront of the development of this new vascular surgical specialty. He brought to it great surgical expertise for those patients who came to Cardiff, but he recognised that in the large, sparsely populated area of Wales there needed to be immediately available local services. Every hospital in Wales could not have a dedicated vascular surgeon but he ensured that in every major district there was a general surgeon whom he had trained to provide immediate and lifesaving care. There is no doubt that many patients throughout the principality owed their lives to Gordon Heard’s superb teaching and training of junior staff. Gordon Heard was born on 23 February 1926 in Rhiwbina, Cardiff, the second son of a geologist at Cardiff University. Several particular events in his life may have been influential in his determination and ability to become a surgeon. In 1939, at the age of 13 and at the outbreak of the war, he became …

Background: Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post-lumbar-puncture complications in this age group. Aims: To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months. Setting: The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia). Participants: Paediatric emergency staff, including residents, registrars and consultants. Methods: Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar-puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA). Results: Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p

AimRecruiting sufficient numbers of nurses can provide a challenge for hospitals. Pharmacists have been identified as being able to support nurses by taking on medicines management tasks alongside traditional nursing responsibilities such as medicines administration and discharge planning.1 At Barts Health NHS Trust there was increased pressure on nursing staff particularly on one of the complex medical wards during the winter pressure months. Paediatric pharmacists were identified as being able to support nurse:Safe nursing time by taking on some of nursing responsibilitiesActive discharge planning and coordinationReduce discharge prescription waiting timesImprove education and training for nurses, doctors and patients in relation to medicines management.MethodA pilot project on one paediatric medical ward was started in February 2016. The pharmacist is supernumerary to standard ward pharmacy service, reporting to the ward manager and lead pharmacist. Working hours are 9 am–5 pm Monday to Friday.Intensive training was provided over 2.5 weeks with subsequent sign off for administration of oral medication, 2nd checking for intravenous (IV) medication and IV giving.Drug listing for discharge prescription (TTA) was introduced, which involves a discussion with the doctor for medicines on discharge, transcribing these onto the TTA and using ward based dispensing where possible. Results were collected pre and post implementation.ResultsMedication administration activity:Nurse time – 60 hours/month (medication administration and 2nd checking) saved.Discharge information:Proportion of TTAs dispensed at ward level increased from 19% to 78% post implementation, avoiding delays in dispensary.Average time writing TTA to being ready for discharge reduced from 280 min to 91 min.Drug listing reduced discharge time further to 52 min.Missed and delayed doses:Random sample of 5 patients audited over 48 hour period, shown to reduce missed doses from 14% to 0%.Comments from staff:‘Because of skill mix and use of agency staff, assisting in preparing and giving IVABs has been a major help as on many days only 1 IV giver.’‘Junior staff value and support WFP and have felt has been useful to them.’‘Junior and agency staff feels better supported in understanding medicines usage’.‘Lot of complex patients with many drugs, the pharmacist has helped reducing delay in administration times’.‘TTAs for patients identified as going home have been validated sooner’.‘She helped us to reduce the number of incidents with expiry dates of medicines’.ConclusionThe role of the medicines facilitation pharmacist has been very well received by the nursing staff and the pharmacist is now an integral part of the ward team. The pharmacist was able to save a significant amount of nursing time and reduced risks of delayed and missed doses significantly and is able to provide continuous input into all aspects of medicines management. The average discharge time has reduced to substantially due to improved discharge planning, drug listing and ward based dispensing.ReferenceRobinson S. Hospital hires pharmacists for wards amid nurse shortage. Pharmaceutical Journal 23/30 May 2015;294(7863/4). [online] doi:10.1211/PJ.2015.20068544

When I was a medical student in the 1960s it was drummed into me that the diagnosis was made from the history, examination and special investigations, but the most important was the history. Despite the explosion of advances during the past 20 years, this is still true today, at least in clinical neurology, and yet histories are becoming increasingly shorter and they are frequently inadequate and incomplete. We enter medicine for many different reasons but I suspect the two most frequently given are a love of meeting people and a desire to help them, but unfortunately because of the pressures we are under, particularly the junior staff, that joy and satisfaction appear to be disappearing and medicine is becoming more mechanical. Protocols and guidelines proliferate at an alarming rate and the emphasis has switched from the history to multiple screening tests and scans. It is now difficult to be seen

Bruce Keogh, national medical director of NHS England, speaks to Abi Rimmer about the need to rebuild junior doctors’ trust The frustration and disillusion experienced by a generation of doctors have featured prominently in media coverage of the dispute between junior doctors and the government over the new contract. Bruce Keogh, NHS England’s national medical director, says that the NHS’s failure to value its juniors is one cause of these doctors’ unhappiness. “Successful companies and successful organisations really spend a lot of time in harnessing the energy, the creativity, the enthusiasm, and the commitment of people in their 20s and 30s—the young professionals who have the energy and the vision,” he says. “I genuinely think that we don’t make the best use of the junior doctors in our NHS.” He adds, “I think that’s become clear in some of the discontent …

Former consultant obstetrician and gynaecologist Hemel Hempstead (b Sri Lanka 1919; q Madras, India, 1948; FRCOG), died on 22 February 2002 following a stroke. Cyril Pallewela worked in Sri Lanka until 1958, when he came to the United Kingdom and continued in the NHS until retirement in 1986. Through his Sri Lankan contacts, he brought into Hemel Hempstead and St Albans many excellent junior staff members who are now settled in senior positions throughout the world. In 2001 Cyril was made a fellow of the newly formed Sri Lankan College of Obstetrics and Gynaecology. After retirement he and his wife, Connie, lived permanently in Sri Lanka but visited the UK most years.

Background and aims Umbilical artery cannulation is a common neonatal procedure that is often challenging because umbilical arteries constrict after birth. We aimed to determine whether the topical application of a vasodilating ointment prior to cannulation increases success and decreases the time taken to cannulate. Methods Discarded umbilical cords were collected immediately after delivery and two 3 cm sections proximal to the baby were used for the study. 0.1mL topical Glyceryl Trinitrate (GTN) ointment (0.2% w/w) was applied to the surface of one section for 5 min prior to cannulation, whereas the second section acted as the control. After ointment removal, medical staff blinded to intervention attempted to cannulate one artery in each section. We assessed cannulation success, time to cannulate, and correct treatment identification for each participant. Results 14 experienced (9 Fellows, 5 Consultants) and 9 junior (Registrars) medical staff attempted 46 cannulations. Experienced participants successfully cannulated 100% of treated and control sections with no significant difference in mean (SD) time to cannulate (98 (75)s and 97(51)s respectively, p = 0.97). Junior participants cannulated 89% and 67% of treated and control sections respectively (p = 0.69), and mean (SD) time to cannulate was 132 (78)s and 106 (53)s respectively (p = 0.42). GTN treated arteries were correctly identified by 43% of experienced and 22% of junior participants (p = 0.47). Conclusions This study suggests that topical application of GTN does not increase successful cannulation of umbilical arteries by experienced staff. More participants or prolonged GTN application time may be needed to confirm these findings in junior staff.

Action is to be taken in Scotland to reduce pressure on junior doctors by ending long stretches of shift working. Junior doctors’ leaders have welcomed plans by the Scottish government to end the practice of rostering junior staff for seven full night shifts in a row. This is to be implemented by February. …

The Future Role of the Consultant (2005) and Safer Childbirth (2007) recommend levels of medical staffing on labour ward depending on the number of deliveries and complexity. Our unit delivers >8000 women/year and as such should have 168 h168 hours of consultant presence plus three junior doctors at ST 1–7 level or equivalent, with only one of these at ST 1–2 level or equivalent. Although no unit in the country has yet achieved these staffing levels, many units are moving towards implementation. We already achieve the junior staffing levels and introduced fixed night consultant presence, initially two nights per week, in March 2012. To assess the impact of this service change, we compared operative intervention rates on the nights with a resident consultant to those nights without, and surveyed all levels of junior staff and midwifery shift leaders regarding different aspects of this service change. We are currently assessing the impact (if any) on clinical incidents. There were no differences in operative intervention rates between the two groups either in terms of caesarean section (15% vs 16%, p = 0.39) or operative vaginal birth (19.5% vs 17%, p = 0.1). Junior doctors felt that they were more supported, more confident, received improved training and had improved decision making when there was a resident consultant, but did not feel disempowered. Both junior doctors and midwives felt more reassured, felt the labour ward ran more smoothly and felt it was easier to involve consultants in decision making when there was a resident consultant. The benefits of consultant presence must be viewed beyond operative intervention rates.

The health secretary Jeremy Hunt blames general practitioners (GPs) for the overcrowding crisis in UK emergency departments,1 because GPs gave up responsibility for out of hours care in 2004. Is this fair? Before 2004, GPs had 24 hour responsibility for patient care. General practice has always been hard work, but demand and expectation were increasing unsustainably in the 1990s. Middle aged GPs (without the protection of junior staff) were often up through the night yet working the next day. Compared with hospital colleagues, the pay and status were poor. GPs were hugely undervalued. General practice was in crisis, with talk …

Objectives: To assess the use of soft collars for whiplash injuries presenting to Welsh accident and emergency departments and compare with recommended treatment as suggested by other literature. Methods: Questionnaires were sent to 76 full time accident and emergency staff across Wales inquiring into their management of soft tissue sprains/strains of the neck and soft collar use. Results: The overall response rate was 74% (SHO 70%, registrar 65%, consultant 100%). Half of consultants and more than half of the middle grade and junior staff reported soft collar use in this condition. As required wear was most commonly recommended and instructions for use ranged from one day only to until the patient was pain free. Conclusion: The study recommends treatment protocols for whiplash injuries prescribing regular analgesia, early home exercises with the help of an advice sheet, and physiotherapy if symptoms persist.

Just under 0.1% of births in England in the decade since 2000 resulted in injuries that led to NHS paying out for damages, says the NHS Litigation Authority.1 In total, compensation claims linked to maternity care led to £3.1bn (€3.9bn; $5bn) in payouts—the most for any specialty—with the largest share of awards (40%) being paid out for cerebral palsy. In its report the authority said that junior doctors and inexperienced midwives were often involved in the labour of the 5087 cases that resulted in claims and that they had not had adequate assistance from senior clinicians. Having more senior staff available during labour, together with a better understanding among junior staff …

Purpose The aim of this study is to evaluate a minimal invasive approach in management of fourth branchial fistula using N Butyl Cyanacrylate (Histoacryl), and to study its feasibility. Patients and Methods Between 2006 and 2011, a retrospective study of 5 children with fourth branchial fistula were treated at Assiut University hospital. Histoacryl (adhesive material) was injected through the tract under general anesthesia. Their age ranged from 2 years to 5.5 years. Three of them were females. Results All the children presented with discharging fourth branchial fistula. Three of them had left sided fistula. Fistulogram was carried out to all cases, 2 of them had complete fistula. The duration of the procedure ranged between ten to fifteen minutes. No complications were recorded. The duration of follow up ranged from two months to one year. No recurrence was recorded during the period of follow up. Conclusion Hisoacryl injection of the fourth branchial fistula is an effective, easy and minimal invasive procedure which can be carried out by junior staff. Surgery is a backup if there is failure or recurrence after injection.

Savings of £290m could be made if all NHS organisations in England reduced their sickness absence rates to that of the lowest quartile, says the Audit Commission. A report, Managing sickness absence in the NHS , found that sickness absence varies considerably around the country from 1.6% to 6.8%. It is highest for primary care trusts and trusts in the North East Strategic Health Authority and lowest in the London Strategic Health Authority area. Ambulance staff, healthcare assistants, and other support staff had the highest rate of sickness absence closely followed by nursing, midwifery, and health visiting staff. The average rates of sickness absence for medical and dental staff was found to be low at 2.1% in hospital trusts and just over 1% in primary care trusts. Generally junior staff were more likely to take time off than their more senior colleagues. The Audit Commission examined data collected from all local …

An unofficial ranking of the results of the 2008 research assessment exercise has allocated two of the top three places to medical research institutions. Heading the list of 132 UK higher education bodies is the Institute of Cancer Research. In third place is the London School of Hygiene and Tropical Medicine. The analysis, which was commissioned by the Times Higher Education and is in its issue of 18/25 December, was greeted with delight by both institutions. “It’s the result of many years of hard work in fostering methodological rigour, supporting junior staff in achieving excellence, and publishing in high impact journals,” said Andrew Haines, director of the School …

When I was a newly qualified doctor, I bought a red Dodge Dart convertible in New York City for $200, drove it across to the west coast, and sold it for $220. My journey took nine months and started a few weeks after I finished my intern year in Brooklyn. My year had begun on a steamily hot August day in the emergency room of the Jewish Hospital and Medical Center of Brooklyn. A mere month after graduating from Aberdeen University I was scarcely equipped for the succession of drug overdoses, knife wounds, and multiple variations on trauma that I saw. Almost all of my patients had been black and Hispanic “service” patients, those without private medical insurance who had been treated in wards bereft of senior staff and relying on the embryonic skills of people like me for their medical care. The junior staff consisted of doctors on rotations from prestigious university teaching hospitals, who resented being obliged to work in this outpost for six months, …

An English hospital trust was last week fined £100 000 (€145 000; $175 000) after pleading guilty to failing to supervise two junior doctors in an orthopaedic ward where a patient died of toxic shock syndrome after a simple knee operation. Southampton University Hospitals NHS Trust was also ordered to pay £10 000 towards the costs of the health and safety prosecution after the death of Sean Phillips, 31, at Southampton General Hospital in June 2000. The fine, which will have to come from the budget for patient care, is a blow to the trust, which overspent by …

Healthcare professionals interested in medical education: junior staff wishing to improve their skills and experienced teachers wanting to keep up to date. During my third and fourth years of specialist registrar training. I am interested in teaching and was keen to know more about educational theory and gain a formal qualification. The units vary, but around 30 hours on each …

Former consultant anaesthetist North Manchester Hospitals (b County Durham 1923; q Durham 1947), died from carcinomatosis on 25 September 2004.​2004. Figure 1 Margaret did her house jobs at the Queen Elizabeth and General hospitals in Birmingham. Her early anaesthetic posts were also in the Birmingham area. She spent seven years as a locum consultant at Selly Oak Hospital before moving to the North Manchester Hospitals, where she was appointed consultant in 1963. She was later appointed an honorary associate lecturer to Manchester University. She played an active role in the teaching of junior staff and was elected vice chairman of the anaesthetic division. Margaret retired in 1985. She never married.

Can patients have too much information about the benefits and harms of treatment? Until a year ago, I wasn't sure of the answer to this. Why worry people needlessly about outcomes that are rarer than hen's teeth? And why burden junior staff with lengthy consent forms? Having just spent the past 12 months being treated for breast cancer, I am now convinced that people need as much good quality information as they can get. Why? Firstly, I wanted to optimise my prognosis by making good decisions. Less obviously, I wanted to be able to comfort myself post hoc that I had made the best decisions possible at the time. (It would be cold comfort were my family and I later to discover reliable research favouring different decisions than was available last year.) Secondly, I needed to recognise the effects of treatment, both good and bad, when they occurred. For example, being aware that neutropenia below about 0.5x109/l carried a small but real risk of …

Editor—As a trial, the study by Kinley et al shows that trained nurses are (approximately) equivalent to house officers at the tasks of conventional preoperative assessment.1 The real question to be asked is why we persist with the ritual of preoperative assessment led by junior staff (of whatever professional discipline) at all. A decade ago, I and my colleages re-engineered preoperative preparation of patients and developed a system that has eliminated the ritual involvement of junior medical staff altogether.2 By using a system led and supervised by a consultant anaesthetist, the tasks of gathering clinical and related information about a patient can be achieved using a combination of methods, including questionnaires, collecting information from general practitioners and other specialists, and selective clinic visits where patients are seen by both nurses and anaesthetists. Thus prepared, patients arrive in hospital two to three hours before surgery, even for major cardiothoracic or vascular surgery. The system has become widespread in most major hospitals in Australia and New Zealand, where hospital practice is broadly similar to that in the United Kingdom. So why compare nurses to house officers? Surely nurses are better than that.

Consultant obstetrician and gynaecologist Queen Mother's Hospital and Western Infirmary (b Ayrshire 1953; q Glasgow 1977; MD, FRCOG, FRCS Glas), died from a heart attack on 15 March 2002. In 1988 he was appointed to his first consultant post at the Royal Alexandra Infirmary, Paisley, moving to the Queen Mother's and Western Infirmary in 1995. David was a true “all rounder.” His involvement with junior staff training led to him being elected regional RCOG adviser in 1999. Trainees found him to be a demanding but inspirational figure. He leaves a partner, Jess; and two sons.

Editor—The Royal College of Paediatrics and Child Health produced recommendations on teaching and training junior doctors involved in neonatal resuscitation.1 These stated that all new staff members should receive an induction programme on neonatal resuscitation that includes practice with mannequins. All should also be familiarised with resuscitation equipment on labour wards and be appraised before being permitted to operate alone. Regular updates on neonatal resuscitation training are also recommended and ideally all junior staff's participation in resuscitation procedures should be formalised and documented. We attempted to assess by telephone questionnaire the current position of neonatal resuscitation training in England and Wales, using a questionnaire of general professional trainees (GPTs). The questionnaire covered key areas within the college recommendations. An attempt within the questionnaire was made to assess …

To investigate the relation between the timing of birth and the occurrence of death related to an intrapartum event.Analysis of 107,206 births to Welsh residents in 1993-5, including 608 cases of stillbirth and 407 of neonatal death identified in the all Wales perinatal survey, the cause of death classified with the clinicopathological system.79 normally formed babies stillborn or who died in the neonatal period, birth weight1499 g, for whom cause of death was related to an intrapartum event.Relative risk of death due to an intrapartum event according to the hour, day, and month of birth.Mortality was higher in babies born between 9.00 pm and 8.59 am than in those born between 9.00 am and 8.59 pm; relative risk (95% confidence interval) 2.18 (1.37 to 3.47). July and August births also had a higher death rate than births in other months; relative risk 1.99 (1.23 to 3.23). Weekened births had a higher death rate but it was not significant.The excess of deaths at night and during months when annual leave is popular may indicate an overreliance on inexperienced staff at these times. Errors of judgement may also be related to physical and mental fatigue, demanding a more disciplined systematic approach at night. Mistakes may be ameliorated by increasing shiftwork, but shifts should be carefully designed to avoid undue disruption of circardian rhythms. In addition, greater supervision by senior staff may be required at night and during summer months.

EDITOR,--David Armstrong and Mick Nicoll do not provide any evidence to justify their assertion that the average consultant saw 1680 new patients in 1949,1 a year in which …

EDITOR,—The recent headlines concerning the lack of intensive care beds in the United Kingdom reflect a longer term crisis that has afflicted intensive care since the first intensive care units were established around 30 years ago. Intensive care units in Britain are still staffed by consultants, many of whom have undergone no systematic training in the specialty, and by resident rotating junior staff, who spend just enough time in the intensive care unit to learn what it is about before moving on. The royal colleges have been talking about training in intensive care for around 10 years now; they have formed one committee after another, written …

An attempt was made to measure the workload of a typical general surgical firm (two part time consultants and their junior staff) serving a population of 100 000 in England and Wales. This provides a background against which to plan curricula for undergraduate and postgraduate teaching, as well as being a guide to the experience that a surgical trainee should get in a suitable training post. The effect of changes in surgical staffing on the number of operations done by a surgeon may also be estimated.

In a 10-year retrospective study of 25 921 consecutive deliveries in a neonatal unit in Newcastle upon Tyne 271 cases of congenital dislocation of the hips were identified. Of these, the outcome was unsatisfactory in 12: four diagnoses were missed at birth and eight children required further surgical treatment. Radiological abnormalities were detected in a further five children at long-term follow-up examination. From the results of this study and other published series it was concluded that lack of attention to detail was the main cause of inadequate diagnosis and management of congenital dislocation of the hips. More detailed instruction of junior staff, confirmation of the diagnosis by senior staff, the use of a non-removable splint early in treatment, and thorough follow-up by senior staff are all important.

In Achieving a Balance the Department of Health published requirements for medical staffing in hospitals. To review the effect that these would be likely to have a study was undertaken in the anaesthetic department of a district general hospital. The results were then validated with staffing levels in a new district general hospital with only one tier of junior staff. It was found that over the next 10 years a massive expansion in the numbers of consultants would be needed at a cost of 108,000 pounds in salaries and employer's contributions alone.